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Mr. Duffy is admitted to the CCU with a diagnosis of R/O MI. He presented in the ER with a
typical description of pain associated with an MI, and is now cold and clammy, pale and
dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy
has not been started, and he is not on the monitor. He is frightened.
1. The nurse is aware of several important tasks that should all be done immediately in
order to give Mr. Duffy the care he needs. Which of the following nursing interventions will
relieve his current myocardial ischemia?
All the nursing interventions listed are important in the care of Mr. Duffy. However relief of
his pain will be best achieved by increasing the O2 content of the blood to his heart, and
relieving the spasm of coronary vessels.
2. During the first three days that Mr. Duffy is in the CCU, a number of diagnostic blood
tests are obtained. Which of the following patterns of cardiac enzyme elevation are most
common following an MI?
Although the timing of initial elevation, peak elevation, and duration of elevation vary with
sources, current literature favors option letter c.
3. On his second day in CCU Mr. Duffy suffers a life-threatening cardiac arrhythmia.
Considering his diagnosis, which is the most probable arrhythmia?
a. atrial tachycardia
b. ventricular fibrillation
c. atrial fibrillation
d. heart block
Ventricular irritability is common in the early post-MI period, which predisposes the client to
ventricular arrhythmias. Heart block and atrial arrhythmias may also be seen post-MI but
ventricular arrhythmias are more common.
4. Mr. Duffy is placed on digitalis on discharge from the hospital. The nurse planning with
him for his discharge should educate him as to the purpose and actions of his new
medication. What should she or he teach Mr. Duffy to do at home to monitor his reaction to
this medication?
All options have some validity. However, option B relates best to the action of digitalis. If
the pulse rate drops below 60 or is markedly irregular, the digitalis should be held and the
physician consulted. Serum potassium levles should be monitored periodically in clients on
digitalis and diuretics, as potassium balance is essential for prevention of arrhythmias.
However the client cannot do this at home. Daily weights may make the client alert to fluid
accumulation, an early sign of CHF. Blood pressure measurement is also helpful; providing
the client has the right size cuff and he or she and/or significant other understand the
technique and can interpret the results meaningfully.
You are speaking to an elderly group of diabetics in the OPD about eye health and the
importance of visits to the ophthalmologist.
5. You decide to discuss glaucoma prevention. Which of the following diagnostic tests should
these clients request from their care provider?
a. fluorescein stain
b. snellen’s test
c. tonometry
d. slit lamp
Option A is most often used to detect corneal lesions; B is a test for visual acuity using
snellen’s chart; D is used to focus on layers of the cornea and lens looking for opacities and
inflammation.
6. You also explain common eye changes associated with aging. One of these is presbyopia,
which is:
a. Refractive error that prevents light rays from coming to a single focus on the retina.
b. Poor distant vision
c. Poor near vision
d. A gradual lessening of the power of accommodation
7. Some of the diabetic clients are interested in understanding what is visualized during
funduscopic examination. During your discussion you describe the macular area as:
a. Head of the optic nerve, seen on the nasal side of the field, lighter in color than the
retina.
b. The area of central vision, seen on the temporal side of the optic disc, which is
quite avascular.
c. Area where the central retinal artery and vein appear on the retina.
d. Reddish orange in color, sometimes stippled.
Options A and C refer to the optic disc, D describes the color of the retina.
8. One of the clients has noted a raised yellow plaque on the nasal side of the conjunctiva.
You explain that this is called:
Correct by definition.
You are caring for Mr. Kaplan who has chronic renal failure (uremia)
9. You know that all but one of the following may eventually result in uremia. Which option
is not implicated?
a. glomerular disease
b. uncontrolled hypertension
c. renal disease secondary to drugs, toxins, infections, or radiations
d. all of the above
Options A, B and C are potential causes of renal damage and eventual renal failure.
Individuals can live very well with only one healthy kidney.
10. You did the initial assessment on Mr. Kaplan when he came to your unit. What classical
signs and symptoms did you note?
Weakness and anorexia are due to progressive renal damage; pruritus is secondary to
presence of urea in the perspiration. Fruity smelling breath is found in diabetic ketoacidosis.
Polyuria, polydipsia, polyphagia are signs of DM and early diabetic ketoacidosis. Oliguria is
seen in chronic renal failure. The skin is more sallow or brown as renal failure continues.
11. Numerous drugs have been used on Mr. Kaplan in an attempt to stabilize him.
Regarding his diagnosis and management of his drugs, you know that:
a. The half-life of many drugs is decreased in uremia; thus dosage may have to be
increased to be effective.
b. Drug toxicity is a major concern in uremia; individualization of therapy and
often a decrease in dose is essential.
c. Drug therapy is not usually affected by this diagnosis
d. Precautions should be taken with prescription drugs, but most OTC medications are safe
for him to use.
Metabolic changes and alterations in excretion put the client with uremia at risk for
development of toxicity to any drug. Thus alteration in drug schedule and dosage is
necessary for safe care.
You are assigned to cardiac clinic to fill in for a colleague for 3 weeks. You begin by
reviewing assessment of the cardiovascular system in your mind and asking yourself the
following:
12. The point of maximum impulse (PMI) is an important landmark in the cardiac exam.
Which statement best describes the location of the PMI in the healthy adult?
a. Base of the heart, 5th intercostal space, 7-9 cm to the left of the midsternal line.
b. Base of the heart, 7th intercostal space, 7-9 cm to the left of the midsternal line.
c. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.
d. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.
The PMI is the impulse at the apex of the heart caused by the beginning of ventricular
systole. It is generally located in the 5th left ICS, 7-9 cm from the MSL or at, or just medial
to, the MCL.
13. During the physical examination of the well adult client, the health care provider
auscultates the heart. When the stethoscope is placed on the 5th intercostal space along the
left sternal border, which valve closure is best evaluated?
a. Tricuspid
b. Pulmonic
c. Aortic
d. Mitral
The sound created by closure of the tricuspid valve is heard at the 5th LICS at the LSB.
Pulmonic closure is best heard at the 2nd LICS, LSB. Aortic closure is best heard at the 2nd
RICS, RSB. Mitral valve closure is best heard at the PMI landmark (apex)
14. The pulmonic component of which heart sound is best heard at the 2nd LICS at the
LSB?
a. S1
b. S2
c. S3
d. S4
S1 is caused by mitral and tricuspid valve closure, S2 is caused by the aortic and pulmonic
valve closure; S3 and S4 are generally considered abnormal heat sounds in adults and are
best heard at the apex.
15. The coronary arteries furnish blood supply to the myocardium. Which of the following is
a true statement relative to the coronary circulation?
a. the right and left coronary arteries are the first of many branches off the ascending aorta
b. blood enters the right and left coronary arteries during systole only
c. the right coronary artery forms almost a complete circle around the heart, yet supplies
only the right ventricle
d. the left coronary artery has two main branches, the left anterior descending and
left circumflex: both supply the left ventricle
The right and left coronary arteries are the only branches off the ascending aorta; blood
enters these arteries mainly during diastole; the right coronary artery also often supplies a
small portion of the left ventricle.
Sally Baker, a 40-year-old woman, is admitted to the hospital with an established diagnosis
of mitral stenosis. She is scheduled for surgery to repair her mitral valve.
16. Ms. Baker has decided to have surgical correction of her stenosed valve at this time
because her subjective complaints of dyspnea, hemoptysis, orthopnea, and paroxysmal
nocturnal dyspnea have become unmanageable. These complaints are probably due to:
Pulmonary congestion secondary to left atrial hypertrophy causes these symptoms. The left
ventricle does not hypertrophy in mitral stenosis; right heart failure would cause abdominal
discomfort and peripheral edema; pericardial thickening does not occur.
17. On physical exam of Ms. Baker, several abnormal findings can be observed. Which of
the following is not one of the usual objective findings associated with mitral stenosis?
Evidence of left atrial enlargement may be seen on chest x-ray and ECG. The other
objective findings may be seen in chronic mitral stenosis with episodes of atrial fibrillation
and right heart failure.
18. You are seeing more clients with diagnoses of mitral valve prolapse. You know those
mitral valve prolapse is usually a benign cardiac condition, but may be associated with
atypical chest pain. This chest pain is probably caused by:
a. ventricular ischemia
b. dysfunction of the left ventricle
c. papillary muscle ischemia and dysfunction
d. cardiac arrythmias
Ventricular ischemia does not occur with prolapsed mitral valve; options B and D are not
painful conditions in themselves.
Mr. Oliver, a long term heavy smoker, is admitted to the hospital for a diagnostic workup.
His possible diagnosis is cancer of the lung.
19. The most common lethal cancer in males between their fifth and seventh decades is:
20. Of the four basic cell types of lung cancer listed below, which is always associated with
smoking?
a. adenocarcinoma
b. squamous cell carcinoma (epidermoid)
c. undifferenciated carcinoma
d. bronchoalveolar carcinoma
21. Chemotherapy may be used in combination with surgery in the treatment of lung
cancer. Special nursing considerations with chemotherapy include all but which of the
following?
a. Helping the client deal with depression secondary to the diagnosis and its treatment
b. Explaining that the reactions to chemotherapy are minimal
c. Careful observation of the IV site of the administration of the drugs
d. Careful attention to blood count results
22. Which of the following operative procedures of the thorax is paired with the correct
definition?
Wedge resection is removal of part of a segment of the lung; decortication is the removal of
a fibrous membrane that develops over the visceral pleura; and thoracoplasty is the
removal of ribs or sections of ribs.
Mr. Liberatore, age 76, is admitted to your unit. He has a past medical history of
hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops
talking in midsentence and stares into space. Today the episode lasted for 15 minutes. The
admission diagnosis is impending CVA.
23. The episodes Mr. Liberatore has been experiencing are probably:
A TIA is a temporary reduction in blood flow to the brain, manifesting itself in symptoms like
those Mr. Liberatore experiences. Although hypo- and hyperglycemia can cause some
drowsiness and/or disorientation, the episodes Mr. Liberatore experiences fit the pattern of
TIA because of his quick recovery with no sequelae and no treatment.
24. Mr. Liberatore suffers a left sided CVA. He is right handed. The nurse should expect:
a. left-sided paralysis
b. visual loss
c. no alterations in speech
d. no impairment of bladder function
Visual field loss is a common side effect of CVA. In right-handed persons the speech center
(Broca’s area) is most commonly in the left brain; because of the crossover of the motor
fibers, a CVA in the left brain will produce a right-sided hemiplegia. Thus, Mr. Liberatore will
probably have some speech disturbance and right-sided paralysis. Often bladder control is
diminished following CVA.
25. Upper motor neuron disease may be manifested in which of the following clinical signs?
Julie, an 18-year-old girl, is brought into the ER by her mother with the chief complaint of
sudden visual disturbance that began half an hour ago and was described as double vision
and flashing lights.
26. During your assessment of Julie she tells you all visual symptoms are gone but that she
now has a severe pounding headache over her left eye. You suspect Julie may have:
a. a tension headache
b. the aura and headache of migraine
c. a brain tumor
d. a conversion reaction
The warning sign or aura is associated with migraine although not everyone with migrane
has an aura. Migraine is usually unilateral and described as pounding. Julie’s symptoms are
most compatible with migraine.
27. You explain to Julie and her mother that migraine headaches are caused by:
The vascular theory best explains migraine and often diagnosis is confirmed through a trial
of ergotamine, which constricts the dilated, pulsating vesels.
28. A thorough history reveals that hormonal changes associated with menstruation may
have triggered Julie’s migraine attack. In investigating Julie’s history what factors would be
least significant in migraine?
a. seasonal allergies
b. trigger foods such as alcohol, MSG, chocolate
c. family history of migraine
d. warning sign of onset, or aura
Sinus headache often accompanies seasonal allergies. Many factors may contribute to
migraine. Usually the client comes from a family that has migrated, which may have been
called “sick headache” due to accompanying nausea and vomiting. Often there is an aura.
Stress, diet, hormonal changes, and fatigue may all be implicated in migraine.
29. A client with muscle contraction headache will exhibit a pattern different for Julie’s.
Which of the following is more compatible with tension headache?
Options A and B describe sinus headache; option A may also be compatible with headache
secondary to eyestrain; option B is also compatible with migraine; option C would be correct
if stated a bandlike “tightness” around the head instead of “burning”
Mr. Snyder is admitted to your unit with a brain tumor. The type of tumor he has is
currently unknown. You begin to think about the way brain tumors are classified.
30. Glioma is an intracranial tumor. Which of the following statements about gliomas do you
know to be false?
a. 50% of all intracranial tumors are gliomas
b. gliomas are usually benign
c. they grow rapidly and often cannot be totally excised from the surrounding tissue
d. most glioma victims die within a year after diagnosis
31. Acoustic neuromas produce symptoms of progressive nerve deafness, tinnitus, and
vertigo due to pressure and eventual destruction of:
a. CN5
b. CN7
c. CN8
d. The ossicles
CN8, the acoustic nerve or vestibulocochlear nerve, is the most commonly affected CN in
acoustic neuroma although as the tumor progresses CN5 and CN7 can be affected.
32. Whether Mr Snyder’s tumor is benign or malignant, it will eventually cause increased
intracranial pressure. Signs and symptoms of increasing intracranial pressure may include
all of the following except:
As ICP increases, the pulse rate decreases and the BP rise. However, as ICP continues to
rise, vital signs may vary considerably.
33. Mr Snyder is scheduled for surgery in the morning, and you are surprised to find out
that there is no order for an enema. You assess the situation and conclude that the reason
for this is:
a. Mr. Snyder has had some mental changes due to the tumor and would find an enema
terribly traumatic
b. Straining to evacuate the enema might increase the intracranial pressure
c. Mr. Snyder had been on clear liquids and then was NPO for several days, so an enema is
not necessary
d. An oversight and you call the physician to obtain the order
Any activity that increases ICP could possibly cause brain herniation. Straining to expel an
enema is one example of how the increased ICP can be further aggravated.
34. Postoperatively Mr. Snyder needs vigilant nursing care including all of the following
except:
Postoperatively clients who have undergone craniotomy usually have their heads elevated
to decrease local edema and also decrease ICP.
35. Potential postintracranial surgery problems include all but which of the following?
a. increased ICP
b. extracranial hemorrhage
c. seizures
d. leakage of cerebrospinal fluid
36. You are responsible for teaching Mrs. Hogan deep breathing and coughing exercises.
Why are these exercises especially important for Mrs. Hogan?
Option A is true: the rationale for deep breathing and coughing is to prevent postoperative
pulmonary complications such as pneumonia and atelectasis. However, the risk of
pulmonary problems is somewhat increased in clients with biliary tract surgery because of
their high abdominal incisions. Option C assumes the stereotype of the person with
gallbladder disease – fair, fat and fory – which is not necessarily the case. Splinting the
incision with the hands or a pillow is very helpful in controlling the pain during coughing.
37. On the morning of Mrs. Hogan’s planned cholecystectomy she awakens with a pain in
her right scapular area and thinks she slept in poor position. While doing the preop check
list you note that on her routine CB report her WBC is 15,000. Your responsibility at this
point is:
A WBC count of 15,000 probably indicates acute cholecystitis, especially considering Mrs.
Hogan’s new pain. The surgeon should be called as he/she may treat the acute attack
medically and delay the surgery for several days, weeks, or months.
38. Mrs. Hogan is scheduled for surgery 2 days later and is to be given atropine 0.3 mg IM
and Demerol 50 mg IM one hour preoperatively. Which nursing actions follow the giving of
the preop medication?
Options A, C and D should all take place prior to administration of the drugs. The family
may also be involved earlier but certainly should have that time immediately after the
medication is given and before it takes full effect to be with their loved ones. Good planning
of nursing care can facilitate this.
39. Mrs. Hogan is transported to the recovery room following her cholecystectomy. As you
continue to check her vital signs you note a continuing trend in Mrs. Hogan’s status: her BP
is gradually dropping and her pulse rate is increasing. Your most appropriate nursing action
is to:
These are signs of impending shock, which may be true shock or a reaction to anesthesia.
Your most appropriate action is to report your findings quickly and accurately and to
continue to monitor Mrs. Hogan carefully.
40. Mrs. Hogan returns to your clinical unit following discharge from the recovery room. Her
vital signs are stable and her family is with her. Postoperative leg exercises should be
inititated:
Leg exercises, deep breathing and coughing, moving, and turning should begin as soon as
the client’s condition is stable. The family can be extremely helpful in encouraging the client
to do them, in supporting the incision, etc. a doctor’s oreder is not necessary – this is a
nursing responsibility.
a. Can be attempted for up to 2 minutes before you need to stop and ventilate the patient.
b. Reduces the risk of aspiration of gastric contents.
c. Should be performed with the neck flexed forward making the chin touch the chest.
d. Should be performed after a patient is found to be not breathing and two breaths have
been given but before checking for a pulse.
Letter A is wrong because an attempt should not last no longer than 30 seconds. Unless
injury is suspected the neck should be slightly flexed and the head extended.. the ‘sniffing
position’. After securing an airway and successfully ventilating the patient with two breaths
you should then check for a pulse. If there is no pulse begin chest compressions. Intubation
is part of the secondary survey ABC’s.
a. Rapid and forceful ventilations are desirable so that adequate ventilation will be assured
b. Effective ventilations can always be given by one person.
c. Cricoid pressure may prevent gastric inflation during ventilations.
d. Tidal volumes will always be larger than when giving mouth to pocket mask ventilations.
Cricoid pressure may prevent gastric inflation during ventilations and may also prevent
regurgitation by compressing the esophagus. Letter A may cause gastric insufflation thus
increasing the risk for regurgitation and aspiration. With adults breaths should be delivered
slowly and steadily over 2 seconds. Effective ventilation using bag-valve mask usually
requires at least two well trained rescuers. A frequent problem with bag-valve mask
ventilations is the inability to provide adequate tidal volumes.
44. If breath sounds are only heard on the right side after intubation:
Most likely you have a right main stem bronchus intubation. Pulling the tube back a few
centimeters may be all you need to do.
EOA insertion should only be attempted by persons highly proficient in their use. Moreover,
since visualization is not required the EOA may be very useful in patient’s when intubation is
contraindicated or not possible. Vomiting and aspiration are possible complications of
insertion and removal of an EOA.
Which is why a normal ECG alone cannot be relied upon to rule out an MI. Chest pain does
not always accompany an MI. This is especially true of patients with diabetes. A targeted
history is often crucial in making the diagnosis of acute MI. The chest pain associated with
an acute MI is often described as heavy, crushing pressure, 'like an elephant sitting on my
chest.'
47. The most common lethal arrhythmia in the first hour of an MI is:
Moreover, ventricular fibrillation is 15 times more likely to occur during the first hour of an
acute MI than the following twelve hours which is why it is vital to decrease the delay
between onset of chest pain and arrival at a medical facility. First degree heart block is not
a lethal arrhythmia.
49. Atropine:
Only give atropine for symptomatic bradycardias. Many physically fit people have resting
heart rates less than 60 bpm. Atropine may be given via an endotracheal tube.
Administering atropine slowly may cause paradoxical bradycardia.
a. True
b. False
Asystole is not amenable to correction by defibrillation. But there is a school of thought that
holds that asystole should be treated like V-fib, i.e... defibrillate it. The thinking is that
human error or equipment malfunction may result in misidentifying V-fib as asystole.
Missing V-fib can have deadly consequences for the patient because V-fib is highly
amenable to correction by defibrillation.